Knowledge, acceptance and concerns regarding COVID-19 vaccination among pregnant women on the east coast of Peninsular Malaysia: A cross-sectional study

Abstract Introduction: This prospective cross-sectional study, conducted from 1 April 2022 to 31 October 2022, aimed to assess the knowledge, acceptance and concerns regarding COVID-19 vaccination among pregnant women visiting the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia. Methods: The study included all pregnant women aged >18 years. Sociodemographic data, information related to COVID-19 and vaccination and information on the knowledge, acceptance and concerns regarding COVID-19 vaccination were collected using a validated questionnaire. Results: Out of 420 eligible pregnant women, 412 participated in the study, yielding a response rate of 98.1%. Of the respondents, 97.1% had received a COVID-19 vaccine, while 2.9% had not. Approximately 85.2% demonstrated a good understanding of COVID-19 vaccination. Among those vaccinated, 76.8% based their decision on recommendations from healthcare providers or the Ministry of Health. Among those unvaccinated, 91.7% believed that COVID-19 vaccines could harm their pregnancy and baby. Although 51% of the respondents expressed concerns about vaccine safety, 202 still chose to be vaccinated, indicating a willingness to prioritise their health despite apprehensions. Conclusion: The study found no significant link between acceptance and good knowledge of COVID-19 vaccination. However, income and prior COVID-19 booster vaccination were strongly associated with acceptance. Despite safety concerns, 97.1% of the respondents had received a COVID-19 vaccine. This emphasises the importance of providing comprehensive information and addressing concerns to support informed decision-making among pregnant women. Healthcare providers play a vital role in guiding them through this crucial decision-making process.


Introduction
COVID-19, originating from a novel coronavirus termed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began in December 2019, initially linked to a Wuhan seafood market. 1 World Health Organization (WHO) declared COVID-19 a pandemic on 11 March 2020 due to escalating global cases. 2 is has left signi cant marks on societies.e consequences of COVID-19 are seen in multiple aspects: psychological, social and economic.Pregnant women are at a higher risk for severe illness in the presence of COVID-19. Aumulating evidence indicates that pregnant women are more likely to develop COVID-19-related complications, including the need for invasive ventilation, admission to an intensive care unit and death, than nonpregnant women.[3][4][5] However, pregnant women have not been included in any trials on COVID-19 vaccination.
In April 2021, the WHO Strategic Advisory Group of Experts on Immunization recommended that pregnant women can receive a COVID-19 vaccine if the bene ts of vaccination outweigh the potential risks, such as occupational activities with an unavoidable high risk of exposure and the presence of comorbidities that place them at a high risk for severe COVID-19. 6e American College of Obstetricians and Gynecologists (ACOG) highlighted that vaccination for pregnant women should be considered on a case-bycase basis after consultation between them and their healthcare providers. 7Pregnant women should be provided with information about the risks of COVID-19 in pregnancy, the potential bene ts of vaccination in the local epidemiological context and the current limitations of vaccine safety data in pregnant women to help them decide.
e Ministry of Health (MOH) Malaysia guidelines recommend mRNA vaccines as the preferred option among pregnant and breastfeeding mothers in Malaysia; at the time, Comirnaty by P zer was the preferred available vaccine. 8 the time of this study, there is no available research on vaccine acceptance among pregnant women locally.In 2020, Azlan et al. investigated public knowledge, attitudes and practices towards COVID-19 in the general Malaysian population rather than in obstetric populations. 9s, this study aimed to evaluate the knowledge level, acceptance rate and concerns of pregnant women regarding COVID-19 vaccination utilising a validated questionnaire.e ndings can be valuable in guiding policymakers in e ectively addressing the concerns of pregnant women and educating them about COVID-19 vaccines.Providing accurate information and addressing such concerns can facilitate e orts to improve vaccine acceptance.

Methods
e sample size for this study was calculated using the single-proportion formula in the Sample Size Calculator (web) by Ari n, with a con dence level of 0.95 and a precision level of 0.05. 10 e proportion used in this calculation was 30.3% of COVID-19 vaccine acceptance among pregnant mothers. 11 sample size calculated considering a 20% dropout rate was 407.Herein, we deliberately collected more samples.
is cross-sectional study was conducted from 1 April 2022 to 31 October 2022.e study employed purposive sampling, targeting pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia (HUSM).Individuals who met the speci ed inclusion criteria were approached, and all eligible individuals who expressed willingness to participate were included in the study until the predetermined sample size was achieved.A questionnaire was distributed during the rst encounter with pregnant women at the Obstetrics and Gynaecology Department of HUSM.
A total of 420 questionnaires were distributed, and 412 pregnant women completed the questionnaires, yielding a response rate of 98.1%.Pregnant women who were aged ≥18 years were included, while those who could not understand Malay or English were excluded.
e questionnaire consisted of two parts.e surveys were conducted using our newly designed validated questionnaire consisting of 24 questions.Eight questions were under the knowledge domain, six items under the acceptance domain and 10 items under the concerns domain, with Cronbach's alpha values for all factors being more than 0.7 (0.738 for knowledge of bene ts, 0.866 for knowledge of side e ects and 0.926 for both acceptance and concerns).
For the knowledge domain, the response options were 'no', 'yes' and 'do not know'.
e scores for correct and incorrect answers were 1 and 0, respectively.Not answering or not knowing was considered neutral and was scored as 0. e maximum possible score was 8. Respondents who obtained scores above the mean total score (≥4.0) were categorised as having good knowledge and those who did not as having poor knowledge.
e nal scores were interpreted as follows: good acceptance (acceptance score equal to or more than the median score) and poor acceptance of COVID-19 vaccination (acceptance score less than the median score).

ORIGINAL ARTICLE
Malays Fam Physician 2024;19:29 3 For the concerns domain, the questions were scored using a Likert scale as follows: 'not concerned at all'=1, 'not concerned'=2, 'a bit concerned'=3, 'concerned'=4 and 'very concerned'=5.'Very concerned', 'concerned' and 'a bit concerned' were combined into one category as 'concerned', while 'not concerned' and 'not concerned at all' were combined into one category as 'not concerned'.
Data were recorded and analysed using IBM SPSS Statistics (Version 27) Armonk,NY,USA.
e sociodemographic data as well as information related to COVID-19 and vaccination of all respondents were analysed using descriptive statistics.Simple and multiple logistic regression analyses were conducted to determine the factors associated with acceptance of COVID-19 vaccination.All variables with P-values of <0.25 in the simple logistic regression analysis were included in the multivariable analysis based on the Wald test by prioritising the important variables to be further evaluated.e level of signi cance was set at 0.05.e results were presented with crude odds ratios (ORs), adjusted ORs, 95% con dence intervals (CIs) and P-values.e dependent variable was COVID-19 vaccine acceptance, while the independent variables were knowledge, age, BMI, race, occupation, parity, gestation, presence of comorbidities, educational level, income, employment as a healthcare worker, history of COVID-19, history of receiving previous vaccines other than COVID-19 vaccines, history of receiving a COVID-19 vaccine and history of receiving a COVID-19 booster dose.

Sociodemographic characteristics and information related to COVID-19 and vaccination
A total of 412 pregnant women answered the questionnaires.e overall mean age and BMI of the respondents were 31.06±5.43years and 29.24±6.32kg/m 2 , respectively.Approximately 69.95% of the respondents were in their third trimester of pregnancy.Four hundred respondents (97.1%) had received a COVID-19 vaccine, and 66 (16.0%) had completed the rst booster dose (Table 1).

Knowledge of COVID-19 vaccination
A total of 351 pregnant women (85.2%) had good knowledge of COVID-19 vaccination.Among them, 342 (97.4%) were vaccinated.Two hundred eighty-seven pregnant women (69.7%) answered correctly about the e ectiveness of COVID-19 vaccines in reducing COVID-19; 279 of them (97.2%) were vaccinated, while only eight (2.8%) were not.Approximately 68.4% knew that vaccination in pregnant women builds antibodies that might protect the baby, and 81.3% knew that COVID-19 vaccines e ectively reduce the severity of infection.More than 60% of the respondents knew all side e ects of COVID-19 vaccines.Nine out of the twelve women who were not vaccinated had good knowledge.

Concerns about COVID-19 vaccination
Two hundred ten respondents (51.0%) were concerned that COVID-19 vaccination would harm their pregnancy.Despite this, 202 of them were vaccinated.Most of the concerns were regarding vaccine safety, in which 48.1% of the respondents were concerned that vaccination would cause a miscarriage, preterm birth or stillbirth, and 48.5% were concerned that it would cause congenital abnormalities.One hundred ninety-ve respondents (47.3%) were concerned about the content or ingredients of a COVID-19 vaccine; however, 187 of them received the vaccination.Of those not vaccinated, 66.7% were mainly concerned about the e ect of a COVID-19 vaccine on their pregnancy and baby, the content of such vaccine and the side e ects post-vaccination (Table 3).

Factors associated with hesitancy or refusal of COVID-19 vaccination
e most common reasons for hesitancy or refusal of COVID-19 vaccination among the unvaccinated respondents were the belief that vaccination would harm the pregnancy and baby and the lack of information regarding the safety of COVID-19 vaccination for pregnant women (both 91.7%).Approximately 25% of the respondents mentioned that they were not vaccinated because their family members were worried about the e ectiveness of a COVID-19 vaccine.None believed that their religion forbids them from receiving COVID-19 vaccination.

Factors associated with acceptance of COVID-19 vaccination
Table 4 presents the results of the simple logistic regression analysis of the factors associated with acceptance of COVID-19 vaccination.
e variables with a P-value of <0.25 were gestation, income, employment as a healthcare worker, history of receiving a previous vaccine other than a COVID-19 vaccine, history of receiving a COVID-19 booster dose and total knowledge score.Table 5 summarises the factors associated with acceptance of COVID-19 vaccination when adjusted for other variables using multiple logistic regression.Two factors -income and history of receiving a COVID-19 booster dose -were signi cantly associated with acceptance of COVID-19 vaccination.e respondents in the M40 and T20 income groups had 1.88 times higher odds of accepting COVID-19 vaccination (95% CI=1.05, 3.37; P=0.034) when adjusted for other variables.However, the exact gures for pregnant women receiving a COVID-19 vaccine are not yet available in any articles or publications.While safety concerns exist for COVID-19 vaccines due to their new technology and the initial exclusion of pregnant women from e cacy trials, emerging data o er reassuring insights into their safety. 13,14 the time of the study, the National COVID-19 Immunisation Programme of Malaysia was already in Phase 5, in which the focus was on adolescents aged 12-17 years.Pregnant women were already o ered vaccination since Phase 2 (April-August 2021), in which they were categorised to be at a high risk for COVID-19.Among 308 respondents, 74.8% relied on the MOH Malaysia website, 65.0% on social media, and 56.6% on electronic mass media for COVID-19 vaccine information.Social media and electronic mass media emerged as primary information sources, emphasizing their importance in communicating vaccination bene ts.Printed media, utilized by only 29.4% of respondents, appeared less e ective.
Even though only 56.6% of the pregnant women in this study showed good acceptance of COVID-19 vaccination, 97.1% had completed two doses of COVID-19 vaccination, while 16.0% had received their initial booster dose.
ese rates align closely with Kalok et al.'s ndings who reported a completion rate of 97.8% for both doses, despite our study's majority (81.3%) coming from a low socioeconomic status. 15Notably, there's no signi cant di erence in vaccination rates between our demographic and the urban, higher socioeconomic status group studied by Kalok et al. is suggests a high level of COVID-19 vaccination completion across socioeconomic backgrounds, highlighting the e ectiveness of vaccination e orts.e gure is also comparable to that of the general population, as reported by the MOH Malaysia. 12In ailand, a neighbouring country of Malaysia, a comparable percentage of acceptance has also been reported (88.3%). 16owever, this gure is high compared with that in other countries such as India (52.0%),][19] e high COVID-19 vaccination rate is likely a result of e ective communication about the risks of complications and demonstrates trust in the MOH, emphasising the critical role of clear information.Furthermore, the widespread availability of free COVID-19 vaccines provided by the Malaysian government may have contributed to this positive response.
e increased vaccination uptake may also be linked to the evolving timeline of the study, where safety concerns are progressively addressed, and more data become available over time.
In this study, 85.2% of the pregnant women had good knowledge of COVID-19 vaccination.Approximately 81.3% answered correctly that a COVID-19 vaccine is e ective in reducing the severity of the infection.Patwardhan et al. also showed that 58.7% of their respondents knew that a COVID-19 vaccine could reduce the severity of the disease. 20 media have played a pivotal role in disseminating vital information about COVID-19 and its impact, particularly on pregnant women.By delivering current and relevant updates, the media have e ectively raised awareness about the virus and its potential risks.Moreover, the media have emphasised the importance and advantages of COVID-19 vaccination, contributing to high vaccine acceptance rates among pregnant women in the community.A notable example that had a signi cant impact was the coverage of a well-known Malaysian singer who tragically passed away from COVID-19 while pregnant.
is reallife case served as a poignant reminder of the severity of the virus's impact on pregnant individuals, prompting heightened awareness and a greater willingness to take preventive measures, including vaccination.is highlights the media's power in in uencing the attitudes and behaviours of pregnant women towards COVID-19 vaccination.E ective communication strategies and targeted messaging are crucial to ensure informed decision-making, underscoring the importance of accurate information dissemination and awareness campaigns.
In  21 Two hundred ninety-nine pregnant women (72.6%) in this study agreed to get vaccinated if their employer or a higher authority mandates vaccination on them.Of the 400 vaccinated pregnant women (71%), 284 received COVID-19 vaccination voluntarily; forty were healthcare workers.
Approximately 2.9% of the respondents in this study were not vaccinated.Of them, 91.7% refused COVID-19 vaccination because of their belief that it would harm their pregnancy and baby and the lack of information regarding the safety of COVID-19 vaccination for pregnant women.Our nding is similar to the earlier reports by Upreti and Godara as well as Nguyen et al. that mentioned the same concerns raised by pregnant women who hesitated or refused to get vaccinated. 17,18A study in Ethiopia among the general population also showed similar results, wherein participants expressed that they were not vaccinated because of insu cient information about the vaccine. 22ur study showed that 210 pregnant women (51.0%) were concerned that COVID-19 vaccination would harm their pregnancy and baby.Despite their concerns, 202 of them received COVID-19 vaccination.Approximately 69% of the pregnant women believed that the vaccine e ectively prevents COVID-19.Upreti and Godara reported similar concerns, with 93.1% of their respondents expressing worries about vaccine safety during pregnancy. 17Kumari et al. also found that 58.5% of their participants felt that a COVID-19 vaccine might have unforeseen e ects on unborn children, indicating a widespread concern that needs to be addressed through education and provision of accurate information about vaccine safety. 23rein, we found no signi cant association between acceptance and good knowledge of COVID-19 vaccination among the pregnant women (P=0.447).Approximately 85.5% of the vaccinated pregnant women and 75% of the unvaccinated pregnant women demonstrated good knowledge of COVID-19 vaccination.Uncertainties surrounding the potential risks to the foetus contribute to hesitancy among pregnant individuals, as they may be apprehensive about the vaccine's impact on their unborn child.Only 26.9% of our respondents had tertiary education, yet a remarkable 93.7% of them exhibited good knowledge.We found a signi cant association between educational level and good knowledge (P<0.001);however, our analysis did not reveal a signi cant association between acceptance and good knowledge of COVID-19 vaccination.is nding di ers from the report by Upreti and Godara, wherein acceptance and good knowledge of COVID-19 vaccination were signi cantly associated with higher educational levels. 17Mose and Yeshaneh also found that good knowledge and good practice of pregnant women towards COVID-19 and its preventive measures were signi cantly associated with acceptance of COVID-19 vaccination. 24Our study demonstrated that higher income (P=0.034)and history of receiving a COVID-19 booster dose (P=0.036) were signi cantly associated with acceptance of COVID-19 vaccination.
is nding aligns with that of Kalok et al., wherein higher income was a signi cant determinant of COVID-19 vaccine acceptance. 15[26] However, our study found no signi cant link between previous non-COVID-19 vaccine history and COVID-19 vaccine acceptance.

Limitations
e study is limited by the uneven distribution of ethnicities, with a predominant Malay population, potentially a ecting the generalisability of the ndings.Additionally, a substantial proportion of the respondents belonged to a lower socioeconomic status, introducing potential bias.

Conclusion
Our study found no signi cant association between acceptance and knowledge of COVID-19 vaccination among the pregnant women.Two factors were identi ed to be signi cantly associated with acceptance of COVID-19 vaccination: income and history of receiving a COVID-19 booster dose.Caution is needed in generalising the results to the broader Malaysian population due to the study limitations.Further research with a more diverse sample is recommended.

Table 1 .
Sociodemographic characteristics and information related to COVID-19 and vaccination among pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia (N=412).

Table 1 . Continued
a Mean (standard deviation)

Table 2 .
Acceptance of COVID-19 vaccination among pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia (N=412).

Table 3 .
Concerns regarding COVID-19 vaccination among pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia.

Table 4 .
Simple logistic regression analysis of the factors associated with acceptance of COVID-19 vaccination among pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia.

Table 5 .
Multiple logistic regression analysis of the factors associated with acceptance of COVID-19 vaccination among pregnant women attending the Obstetrics and Gynaecology Department of Hospital Universiti Sains Malaysia.
However, we did not nd any signi cant association between employment status, employment as a healthcare worker and history of COVID-19 and COVID-19 vaccine acceptance.Research by Dolu et al. and Malik et al. indicated that prior vaccine recipients were more inclined to accept COVID-19 vaccination.